Provider Demographics
NPI:1033135397
Name:KLEIN, ANDREA R (PHD)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:R
Last Name:KLEIN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 W. PARK ST.
Mailing Address - Street 2:BWPC
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-2500
Mailing Address - Country:US
Mailing Address - Phone:217-383-6792
Mailing Address - Fax:
Practice Address - Street 1:1701 W. CURTIS ROAD
Practice Address - Street 2:PSYCHOLOGY
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61822
Practice Address - Country:US
Practice Address - Phone:217-365-6206
Practice Address - Fax:217-326-1234
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2015-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071005099103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL6447860004Medicare NSC
ILR58430Medicare UPIN
R58430Medicare UPIN
ILIL3270502Medicare PIN